COVER: 4-year-old Jan Carlos jumps on his parents bed. The family reported a significant drop in the number of malaria cases since

Results Report 215

COVER: 4-year-old Jan Carlos jumps on his parents bed. The family reported a significant drop in the number of malaria cases since insecticide-treated nets were distributed two years ago to all families in this community near Tocoa, Honduras. Honduras The Global Fund / John Rae THIS PAGE: Early morning in Matabele North Province, Zimbabwe. This team of spray operators are carrying out a campaign to spray all homesteads to kill malarial mosquito larvae and protect the families from malaria. Zimbabwe The Global Fund / John Rae

Table of Contents Executive Summary 3 A 21st-century Partnership 5 Impact and Results 7 Building Resilient and Sustainable Systems for Health 27 Adolescent Girls and Women 3 Human Rights 33 Domestic Financing and Sustainability 36 Finances 42 Conclusion 48

17 Million 1/3 fewer deaths lives saved through the Global Fund partnership from AIDS, TB and malaria in countries where the Global Fund invests At the Idinah-Kelo health center in Kelo, Chad, Matron Djekorminde examines a child who is recovering from malaria, thanks to treatment provided with Global Fund support. The child s family also received an insecticide-treated net that gives protection against future infection. Chad The Global Fund / Andrew Esiebo The Global Fund 2

Executive Summary The Global Fund partnership brings together a myriad of strengths: finances; technical expertise; the experience and knowledge of communities affected by HIV, tuberculosis and malaria; innovation; and a capacity for constant evolution. The partners who comprise the Global Fund come with diverse abilities and points of view, yet they share a determination to serve people, to strive for social justice, and to achieve impact against HIV, TB and malaria and ultimately end the epidemics. This report delivers a summary of the impact and results the Global Fund partnership was able to achieve by 215, showing cumulative progress since the Global Fund was created in 22. It is a collective effort, combining the strong contributions made by governments, civil society, the private sector and people affected by HIV, TB and malaria. Here are the cumulative highlights: 17 million lives saved; on track to reach 22 million lives saved by the end of 216 A decline of one-third in the number of people dying from HIV, TB and malaria since 22, in countries where the Global Fund invests 8.1 million people on antiretroviral treatment for HIV 13.2 million people have received TB treatment 548 million mosquito nets distributed through programs for malaria Building resilient and sustainable systems for health is critically important to end HIV, TB and malaria as epidemics. The Global Fund partnership s investments in HIV, TB and malaria create substantial positive effects on the systems for health in countries where these diseases are rife. This mutually reinforcing relationship between funding for disease-control programs and funding for cross-cutting systems is a cornerstone of the Global Fund s approach to investment. Overall, more than one-third of the Global Fund s investments go to building resilient and sustainable systems for health. of its investments benefit women and girls, with a positive impact on reproductive health. Human rights are built into the Global Fund s strategy, by increasing investments in programs that address human rights barriers and cutting support for programs that infringe on human rights. The Global Fund works with partners to identify gaps and help shape investments more effectively. Respecting and promoting human rights is essential for expanding access to health services. The Global Fund is embedding human rights work into the grant-making process. The Global Fund has found an effective way to stimulate domestic investments in health. In 214, the Global Fund partnership began full implementation of a funding model with a counterpart financing requirement in order to access full funding. A 52 percent increase in domestic investments in health is projected, an additional investment of US$4.5 billion committed from government resources for 215-217, compared with the amount invested in 212-214. Global Fund investment in health programs has grown steadily. As of September 215, the Global Fund disbursed US$27 billion to support programs for HIV, TB and malaria. By 215, the Global Fund achieved two-year savings worth more than US$5 million through more effective procurement. The medicines and health products purchased through a pooled procurement mechanism were delivered more swiftly than in the past, with on time delivery improving from 36 percent in 213 to 81 percent in 215. Operating expenditure is decreasing, through disciplined cost control, efforts to save money and adherence to a prudent budgeting framework. In 214, operating expenses totaled US$286 million, below a projected budget of US$3 million. That represents about 2.3 percent of grants under management, reflecting a high degree of efficiency compared with other international organizations. Gender inequalities are major drivers of disease transmission and affect the ability of people to access health care and other services equitably. In many countries, HIV is the leading cause of death of women of reproductive age. In some, girls account for more than 8 percent of all new HIV infections among adolescents. The Global Fund partnership is committed to striving for equal access to prevention, treatment, care and support for all those who need it, and reducing gender inequality. The Global Fund estimates that approximately 55 to 6 percent To make a transformational difference in the lives of people affected by HIV, TB and malaria, the Global Fund partnership must strive to constantly improve. Better data and better tracking of results and impact are needed. So are bedrock principles of partnership and shared responsibility. In 215, as world leaders coalesce to formulate sustainable development goals to improve the lives of billions of people, the achievements of global health can serve as a model for what can be achieved when communities come together and aim for common goals, like access to quality health care for all. Executive Summary 3

this PAGE: Ma Yee Yee (right) could barely walk when she first came to the clinic for a chest X-ray, and was diagnosed with TB. Co-infected with HIV, she still relies on family for help (including her sister, left), but since she started treatment her TB symptoms are diminishing, and her CD4 count has risen dramatically. Myanmar The Global Fund / John Rae Opposite PAGE: Community care workers from the nongovernmental organization TB/HIV Cares make home visits to township communities near Cape Town. These visits are part of a program to help TB patients adhere to treatment. South Africa the Global Fund / John Rae The Global Fund 4

A 21st-century Partnership The Global Fund was designed as a partnership to fight HIV, TB and malaria, and to constantly evolve to meet connected challenges in global health. Only through partnership can the Global Fund achieve the collective vision of a world free of the burden of HIV, TB and malaria. Partnership means constant growth, driven by mutual respect, shared responsibility and a strong commitment by all. A 21st-century partnership takes a modern approach to global health: to be effective, it must be agile, responsive and committed to serving communities affected by HIV, TB and malaria. It must also reach beyond the mindset of paternalistic aid that sometimes created obstacles in the past. With a more modern outlook, countries take the lead in determining where and how best to fight diseases, how to respond to broader development challenges, and how to coordinate work with international partners in global health. They also plan how to use their increased domestic finances to leverage external resources to build resilient and sustainable systems for health. With implementing countries in the lead, partners can take a differentiated approach to investment. That means the partnership s investments are informed by the specific needs and characteristics of each country, as well as the different needs of various communities most affected by diseases. Working together, partnership can deliver healthier and more productive and stable families, communities and nations. The Global Fund s partnership model, made up of governments, civil society, the private sector and people affected by the diseases, brings together many strengths: financing; technical expertise; experience and knowledge of the communities affected by HIV, TB and malaria; innovation; and a capacity for constant evolution. With these assets, the partnership strives to achieve the best possible impact from the investments it makes. Looking to the post-millennium Development Goal era and universal health coverage, the Global Fund is exploring the best possible ways to invest in global health over the next 15 years. Making a transformational difference in the lives of the millions of people affected by diseases in low- and middleincome countries will require significantly bigger domestic investments in health both public and private. Increased domestic investments in health signal country ownership and are a pathway to real sustainability of programs. The Global Fund partnership is already stimulating more domestic investments in health, described in the Domestic Financing and Sustainability section of this report. Only through partnership can the Global Fund achieve the collective vision of a world free of the burden of HIV, TB and malaria. A 21st-century Partnership 5

8.1 Million 13.2 Million 548 Million people on antiretroviral therapy for HIV people have received TB treatment mosquito nets distributed by programs for malaria Villagers gather in a remote area of Sofala Province to receive free mosquito nets as part of a national campaign to reach all families in need of nets. Mozambique the Global Fund / John Rae The Global Fund 6

Impact and Results Lives Saved Number of Lives Saved through Global Fund-supported Programs US$ (Billion) LIVES SAVED (Million) US$4 22 US$3 17m 17 US$2 11 US$1 6 US$ 25 26 27 28 29 21 211 212 213 214 215 216 YEAR Amount disbursed (cumulative) Number of lives saved (cumulative) The impact of investments in health can be measured in many ways, and one of the most important measures is how many lives are saved. Health programs supported by the Global Fund partnership had saved 17 million lives as of end 214. Current projections for 215 and 216 show that health programs supported by the Global Fund partnership are saving approximately 2 million lives each year. If current trends hold, by the end of 216 the Global Fund partnership will support countries in saving a total of 22 million lives since its first grants were made in 22. In 2, AIDS, TB and malaria appeared to be unstoppable. Hard work by many partners has succeeded in reversing the situation by creating significant advances in prevention and increased access to treatment and care for people affected by the diseases. Investments by the Global Fund partnership have grown aggressively, supporting a dramatic expansion of ARV therapy, treatment for TB, and distribution of insecticidetreated nets, as well as building resilient and sustainable systems for health. It is a remarkable achievement, and a credit to the hard work of many partners who created significant advances in prevention and increased access to treatment and care. Overall, the number of deaths caused by AIDS, TB and malaria each year has been reduced by more than one-third since 22 in countries where the Global Fund invests, from 4.2 million in 22 to 2.7 million in 214. The Global Fund Strategy 212-216 set a target of averting 14-18 million infections by the end of 216. If the recent declining trends in number of infections is maintained, the target for averting infections will be met. A Note on Methodology The Global Fund Strategy 212-216 set a target of saving 1 million lives in the five-year period ending 31 December 216. Current projections are on track to achieve that milestone. In 215, the Global Fund partnership is using an improved methodology to estimate lives saved, better aligned with methods used by partners. As in the past, the methodology employs models that analyze raw data. These models Impact and Results 7

represent the most scientifically advanced methods currently available, and use widely accepted data sources. The models yield sophisticated estimates, not scientifically exact figures. The Global Fund Strategic Review 215, produced by a group of independent technical experts, confirmed the credibility of the modeling and the estimates used by the Global Fund. The number of lives saved in a given country in a particular year is estimated by subtracting the actual number of deaths from the number of deaths that would have occurred in a scenario where key disease interventions did not take place. For example, in a country where studies show that 7 percent of smear-positive TB patients will die in the absence of treatment, if 1, smear-positive TB patients were treated in a particular year, yet only 1 people were recorded as dying from TB, the model can conclude that 6 lives were saved. Without treatment, 7 would have died. The Global Fund has been adopting specific methods recommended by its technical partners to estimate lives saved in countries where the Global Fund invests. 1,2 The lives saved estimates are generated by WHO and UNAIDS in consultation with countries, using transmission or statistical disease models such as the UNAIDS Spectrum AIM model, and using the best available data from multiple sources such as routine surveillance, population-based surveys and vital registration systems. The Global Fund contribution to the lives saved by each program is then estimated by applying a percentage contribution by the Global Fund in selected key services. That percentage is applied to the total number of lives saved by each program to arrive at the number of lives saved through Global Fund support. In 215, following short-term recommendations made by an independent expert group in 214, the Global Fund has further improved the methodology to estimate the impact of its investments. One important improvement was the inclusion of impact of all interventions for TB and malaria, instead of limiting them to the impact of mosquito nets and TB treatment. This is leading to higher estimates of lives saved compared to what was recorded in previously published reports. The Global Fund continues to work with partners to further improve the current methodology based on the long-term recommendations of the 214 expert panel. 3 This will include the impact of HIV prevention on the number of lives saved that is currently missing, a factor that may indicate that the Global Fund underestimates the number of lives saved through its investments. It will also address some limitations in the methodology for estimating lives saved from TB and malaria which might over-estimate lives saved in certain settings. Decline in HIV Burden The number of deaths caused by AIDS is declining in countries where the Global Fund invests a more than 4 percent reduction in deaths, from 2 million in 24 to 1.1 million in 214. The graph on the following page illustrates an estimate of how many deaths would have occurred without investments in HIV programs, which grew steadily in this period. When Nelson Mandela spoke at the International AIDS Conference in Durban, South Africa, in July 2, he spoke of a tragedy of unprecedented proportions, and observed that AIDS was claiming more lives than the sum total of all wars, famines and floods. At the time, many people feared that it would be impossible to reverse the course of the epidemic. After peaking in 24, the number of deaths have fallen each year since. The credit for this remarkable turnaround goes to the collective determination and hard work of partners in global health, as well as the visionary leadership of Mandela and others. The work has been complex and challenging, yet more has been achieved in 15 years than almost anyone thought possible in 2. The rapid increase in access to antiretroviral (ARV) therapy in countries supported by the Global Fund from 4 percent coverage in 25 to 21 percent in 21 and 4 percent coverage in 214 has been a tremendous contributing factor. The number of new HIV infections is falling. Between 2 and 214, the number of new HIV infections declined by 36 percent in countries supported by the Global Fund. Partners express optimism that the rate of averting infections can accelerate more sharply if funding continues to grow. Another important factor is the expansion of national coverage of prevention of mother-to-child transmission, reaching 57 percent in 211 and 73 percent in 214. The Millennium Development Goal of reversing the spread of HIV has been achieved in many countries. More than 75 percent of high-impact countries where the Global Fund invests and where quality data are available have reduced the incidence of HIV by 5 percent or more. Yet the global scope of AIDS is still substantial. In total, 34 million people have died from AIDS-related causes as of end 214. There is still more work to do. The Global Fund 8

Trends in AIDS-related deaths (2-214) in Global Fund-supported Countries Trends in new HIV infections (2-214) in Global Fund-supported Countries AIDS-related Deaths (million) DISBURSEMENT (US$ billion) NUMBER OF NEW HIV INFECTIONS (MILLION) DISBURSEMENT (US$ billion) 3. 16 14 5. 16 14 12 4. 12 2. 1 3. 1 8 8 1. 6 4 2. 1. 6 4 2 2 2 22 24 26 28 21 212 214 2 22 24 26 28 21 212 214 YEAR YEAR Global Fund disbursements to HIV programs (cumulative) AIDS deaths actual AIDS deaths no ARV therapy no prevention Global Fund disbursements to HIV programs (cumulative) HIV new infections actual HIV new infections no ARV therapy no prevention Source: UNAIDS Access to ARV therapy has grown from 4 percent coverage in 25 to 21 percent in 21 and 4 percent coverage in 214. Justa Catalina Suazo Dolmo, an HIV activist who runs a support group in Trujillo, Honduras, shows her ARVs. She teaches others living with HIV to fall in love with the treatment, in order to encourage adherence. Honduras The Global Fund / John Rae 1 Ryuichi Komatsu et al. Lives saved by Global Fund-supported HIV/AIDS, tuberculosis and malaria programs: estimation approach and results between 23 and end-27. BMC Infectious Diseases 21, 1:19 doi:1.1186/1471-2334-1-19. 2 Global Fund 212-216 Strategy Technical partner consultation on Goals, Service targets and Impact modelling, Montreux, 7-8th July 211. 3 Expert Panel on Health Impact of Global Fund Investments Geneva, 1 11 July 214. Impact and Results 9

Number of People on Antiretroviral Therapy people (million) US$ (Billion) 9 2 7 15 5 1 2 6 22 23 24 25 26 27 28 29 21 211 212 213 214 YEAR Global Fund Disbursements to HIV programs Number of people currently on ARV therapy HIV: Results for key interventions supported by the Global Fund Since 22, the Global Fund has funded programs to fight HIV in more than 1 countries with high disease burden; where the proportion of key populations is highest; and where the national health systems lack capacity to respond to the disease. The majority of the Global Fund s HIV investments are targeted at countries in sub-saharan Africa, which have been the hardest hit by HIV. Strategic investments have gone to many other countries where key populations have challenges accessing health care. The number of people on ARV therapy in programs supported by the Global Fund has reached 8.1 million, with steady increases each year. Greater Global Fund investment in ARV therapy track effectively in the same direction, and have produced accelerated progress in recent years. The Global Fund Strategy 212-216 set a target of 7.3 million people on anti-retroviral therapy by the end of 216. That target was achieved in 214. Globally, as a result of the collective efforts of all governments and partners, nearly 4 percent of all people living with HIV now have access to ARV therapy a striking increase from less than 1 percent in 2 and just 4 percent in 25. A leading factor in expanding access to treatment is reducing prices for ARVs. A new purchasing framework for ARVs, agreed upon by partners in late 214, is allowing a pooled procurement mechanism to deliver HIV drugs more effectively and reliably and at sharply lower cost. In 2, a one-year supply of ARVs cost more than US$1,. It can now cost less than US$1. Production of generic ARVs was a key factor in the price reduction. Large financing and related volume increases have also been important. Counseling and testing for HIV is a critically important part of prevention and treatment of people living with HIV. Programs supported by the Global Fund have provided counseling and testing for more than 423 million people. Prevention of mother-to-child transmission of HIV is an area of strong focus. The number of HIV-positive women who have received services since 22 to prevent transmission of HIV to unborn children has reached 3.1 million. One simple but effective tool for preventing the spread of HIV is condom use. More than 5.1 billion condoms have been distributed in programs supported by the Global Fund. Treating people for related sexually transmitted diseases is also an important facet of HIV prevention and treatment. More than 22 million people have been treated for sexually transmitted diseases in programs supported by the Global Fund. Putting more people on HIV treatment has an important bearing on reducing stigma associated with the disease. There is evidence to show that expanding HIV treatment lessens stigmatizing attitudes in the general population. A recent study published by the American Journal of Public Health drew parallels between declining stigma in African countries and expansion of HIV treatment. The study, conducted in 18 countries, found a statistically significant association between the proportion of people on HIV treatment and the percentage of the general population endorsing HIV-related stigma. The Global Fund 1

Country Example Kenya With 1.6 million people living with HIV, Kenya has the fourthlargest number of people infected with the virus in the world. The number of new infections each year has dropped at a relatively slow pace. However, accelerated expansion of treatment has meant that many more people who contract HIV are staying alive. About 7, people are now on HIV treatment in Kenya, and 53, women receive prevention of mother-to-child transmission services representing more than 7 percent coverage. Strong HIV testing campaigns have seen 75 percent of Kenyans test for the virus at least once. Fifty percent of people living with HIV in the country know their status. Also, expanded prevention efforts in providing voluntary medical male circumcision have led to 8, circumcisions. Here, an HIV patient is examined at the Ishiara sub-district Hospital in Kenya. According to the doctor he will probably make it. More than 38, people currently receive lifesaving treatment for HIV in Kenya, with Global Fund support. Kenya The Global Fund / John Rae Lives Saved and New HIV Infections, Kenya Number of cases (thousands) DISBURSEMENTS, CUMULATIVE (US$ MILLION) 5 45 25 4 35 3 25 2 15 1 5 2 15 1 5 24 25 26 27 28 29 21 211 212 213 YEAR Global Fund disbursements (cumulative, right axis) Number of new HIV infections (left axis) Number of lives saved (cumulative, left axis) Source: Spectrum Goals model for estimate of new infections and lives saved Impact and Results 11

Decline in TB Burden The number of deaths from TB declined 29 percent between 2 and 214 in countries where the Global Fund invests. (Deaths from co-infection of HIV and TB are not included in that number.) The number of deaths from TB in 214 would have been more than three times higher in the absence of interventions. The global burden of TB is disproportionately borne by 22 high-burden countries, and efforts on treatment and prevention are being concentrated there. countries where the Global Fund invests, went down by 6 percent between 25 and 214. But the number of cases would have been sharply higher without key interventions. The Millennium Development Goal target of achieving a declining trend in TB incidence has been met. 8 percent of the Global Fund s high-impact countries with accessible data have bent the curve of TB incidence downward. The decline in deaths was supported by an increase in the number of TB cases detected and treated over the past decade. The number of TB cases averted has been growing each year, with a substantial increase in funding for TB prevention, diagnosis and treatment. The number of TB cases, in Separately, if trends continue, the StopTB Partnership target of halving prevalence and mortality rates by 215 from the 199 baseline will also have been met. However, additional funding and increased focus on TB will be required in order to meet the proposed Sustainable Development Goal of ending TB as an epidemic by 23. The global burden of TB is disproportionately borne by 22 countries, and efforts of treatment and prevention are concentrated there. The Global Fund 12

Graph title opposite PAGE: A doctor examines the x-ray of a TB patient at the regional TB hospital in Fergana, Uzbekistan. Treatment for TB is provided free of charge with support from a Global Fund grant. The hospital also conducts outreach activities in schools and the local community to raise awareness and reduce stigma around the disease. Uzbekistan The Global Fund / John Rae THIS PAGE: 4-year-old Lito just completed his treatment for TB. Because children in impoverished families often don t have access to good nutrition, Lito also received dietary supplements that help speed up recovery. El Salvador The Global Fund / John Rae TrendS in Tuberculosis Deaths (2-214) in Global Fund-supported Countries Trends in Incidence of Tuberculosis (2-214) in Global Fund-supported Countries 4. 3. 2. 1. NUMBER OF TB DEATHS excluding HIV-positive (MILLION) 2 YEAR DISBURSEMENT TB (US$ billion) 22 24 26 28 21 212 214 5 4 3 2 1 13. 12. 11. 1. 9. 8. 7. 6. 5. 4. 3. 2. 1. NUMBER OF NEW TB CASES (MILLION) 2 YEAR DISBURSEMENT TB (US$ billion) 22 24 26 28 21 212 214 5 4 3 2 1 Global Fund disbursements to TB programs (cumulative) TB deaths actual TB deaths no DOTS Global Fund disbursements to TB programs (cumulative) New TB cases - actual New TB cases - no DOTS Source: WHO Global TB Program Impact and Results 13

Number of People Treated for Tuberculosis (22-214) Smear-positive TB (Million) US$ (Billion) 14 5 12 4 1 8 3 6 2 4 1 2 22 23 24 25 26 27 28 29 21 211 212 213 214 YEAR Global Fund disbursements to TB programs (cumulative) DOTS (cumulative, left axis) TB: Results for key interventions supported by the Global Fund The Global Fund provides more than three-quarters of all international financing for TB, and has disbursed more than US$4.7 billion in TB programs in more than 1 countries since 22, focusing in particular on countries with the highest disease burden and with the highest proportion of key affected populations, including people living with HIV, migrants, miners, prisoners, children in contact with TB cases and people who use drugs. TB is a disease closely associated with poverty and poor living conditions, with 8 percent of all infections occurring in 22 countries in Africa, South-East Asia and the Western Pacific. Multidrug-resistant TB mutations that cause resistance to first-line treatment has received increasing attention as it grows into a potentially catastrophic threat to public health, especially in Eastern Europe and parts of southern Africa, where it is closely related to those affected by HIV. The number of people being treated for multidrugresistant forms of TB has increased nearly four-fold since 21, reaching 21,. A total of 8.5 million TB patients all forms (smear-positive as well as smear-negative and extra-pulmonary) received treatment between 212 and 214. The Global Fund target of treating 15 million TB patients of all forms over the 212-216 period is proving ambitious. The number of people who have received treatment for smear-positive TB is 13.2 million since 22. in countries where the Global Fund partnership has invested in the fight against TB. That is a 6 percent increase compared with 21. The Global Fund 14

Country Example Bangladesh While TB remains one of Bangladesh s biggest public health challenges, the country has made significant gains against the disease through successful diagnosis and treatment. Fully directly observed treatment, short-course (DOTS) has been available nationally since 26. Global Fund grants have primarily focused on scaling up detection and treatment as well as joint TB/HIV activities. With more than US$143 million invested since 24, more than 577, infections have been averted and more than 38, lives have been saved. However, TB is still claiming 8, lives a year in Bangladesh. The Global Fund will continue to support TB programs in the country with an additional investment of US$9 million in the 214-216 period. For example, because TB is generally transmitted in crowded and poorly ventilated spaces, residents of Chittagong s Tigerpass Railway slum are at high risk of falling ill with TB. With Global Fund support, the government of Bangladesh is working in partnership with civil society organizations to provide thousands of poor residents with treatment and care for TB. Bangladesh The Global Fund / Saiful Huq Omi Lives Saved and Incidence of Tuberculosis, Bangladesh (24-213) Number of cases (thousands) Disbursements, cumulative (US$ Million) 4 35 3 25 2 15 1 5 3 25 2 15 1 5 24 25 26 27 28 29 21 211 212 213 YEAR Global Fund disbursements to TB programs (cumulative, right axis) Number of new TB cases (left axis) Lives saved (cumulative, left axis) Source: TIME model Impact and Results 15

Country Example Tanzania The number of TB cases identified in the country rose sharply between 1995 and 25, prompting the country to declare a national emergency in 26. The Global Fund began supporting TB programs in 27, and joint efforts have averted 328, cases and saved 195, lives since 2. Tanzania has implemented a strong focus on joint TB/HIV interventions, building resilient and sustainable systems for health and improving TB detection and treatment rates. One example is Salma, who, at age 2, was diagnosed with multidrug-resistant TB. She was transferred to Kibong oto National TB Hospital in Arusha - the only hospital in Tanzania that treats multidrug-resistant patients. Tanzania The Global Fund / Mia Collis Lives Saved and Incidence of Tuberculosis, Tanzania (24-213) Number of cases (thousands) Disbursements, cumulative (US$ Million) 2 18 16 14 12 1 8 6 4 2 4 35 3 25 2 15 1 5 24 25 26 27 28 29 21 211 212 213 YEAR Global Fund disbursements to TB programs (cumulative) Number of new TB infections (left axis) Lives saved (cumulative, left axis) The Global Fund 16

Trends in malaria deaths (2-214) in Global Fund-supported Countries Trends in Incidence of Malaria (2-214) in Global Fund-supported Countries NUMBER OF MALARIA DEATHS (MILLION) DISBURSEMENT Malaria (US$ billion) NUMBER OF NEW MALARIA CASES (MILLION) DISBURSEMENT MALARIA (US$ billion) 1.5 8 4 8 7 35 7 6 3 6 1. 5 25 5 4 2 4.5 3 15 3 2 1 2 1 5 1 2 YEAR 22 24 26 28 21 212 214 2 22 24 26 28 21 212 214 YEAR Global Fund disbursements to malaria programs (cumulative, right axis) Malaria deaths actual Malaria deaths no malaria control Global Fund disbursements to malaria programs (cumulative, right axis) New malaria cases actual New malaria cases no malaria control Source: WHO Global Malaria Program Decline in Malaria Burden The number of deaths caused by malaria declined 48 percent between 2 and 214. The number of lives saved by malaria treatment and prevention has grown steadily each year. Children under the age of five are the most vulnerable to malaria, because their immune systems are still developing effective resistance to the disease. Pregnant women are also vulnerable, because their immune systems are weakened during pregnancy. Protecting young children and pregnant women is paramount to any disease strategy. The innovation of a long-lasting insecticidal mosquito net, at a relatively low cost, has greatly expanded protection for children and families. With more than 548 million mosquito nets distributed, people at risk for malaria who gained access to mosquito nets grew from 7 percent in 25 to 36 percent in 21 and 56 percent in 214 in countries where the Global Fund invests. Mosquito nets are just one tool, however, and a comprehensive approach to reducing deaths from malaria includes other preventive measures such as indoor residual spraying. More important, access to artemisininbased combination therapies (ACTs) and to rapid diagnostic tests has improved dramatically. Cases of malaria treated rose 19 percent to hit a cumulative total of 515 million by end 214. The malaria target under Millennium Development Goal 6 has been met, and 55 countries are on track to reduce their malaria burden by 75 percent or more, in line with a target for 215 set by the World Health Assembly in 25. An increasing number of countries are reducing the serious effects of malaria, with the extensive expansion of treatment and prevention, and 11 countries are currently in the pre-elimination phase of disease control. The number of malaria cases averted has grown rapidly, and reached more than 155 million in 214. There was a 17 percent decline in malaria cases between 25 and 214. Malaria is endemic in 97 countries, causing more than 2 million cases each year, most of them in sub-saharan Africa. Every disease-carrying mosquito that is eliminated can reduce the chances that a child under five dies from malaria. Impact and Results 17

The Global Fund has invested more than US$7 billion in programs that prevent and treat malaria, using a comprehensive approach that combines education, prevention, diagnosis and treatment. A villager in Prongyeang, Kanthout commune, Cambodia, carries a new set of insecticide-treated nets that will protect her family against mosquitoes that could carry the malaria parasite. A distribution of the nets took place earlier in the day. Cambodia The Global Fund / John Rae The Global Fund 18

Number of Insecticide-treated Nets Distributed (23-214) nets (Million) US$ (Billion) 12 6 45 9 3 6 15 3 23 24 25 26 27 28 29 21 211 212 213 214 YEAR Global Fund disbursements to malaria programs (cumulative, right axis) Number of insecticide-treated nets distributed (cumulative, left axis) Malaria: Results for key interventions supported by the Global Fund The Global Fund has invested more than US$7 billion in programs that prevent and treat malaria, using a comprehensive approach that combines education, prevention, diagnosis and treatment. In particular, programs focus on pregnant women and children under the age of five, who are especially vulnerable to the disease. Malaria prevention and treatment relies on multiple tools, and the simplest and most effective preventive tool is a longlasting insecticidal net that a family can hang over a place where children sleep. Not only does a net protect a sleeping child from a mosquito bite, but the insecticide on a net also eliminates mosquitoes carrying the disease. Programs supported by the Global Fund have distributed 548 million nets, achieving universal coverage in some countries. When mosquito nets are distributed, they are accompanied by education about how they should be used to best protect families from malaria. A total of 219 million mosquito nets were distributed between 212 and 214 in sub-saharan Africa, the region with the highest malaria burden and the lowest capacity to pay. Current projections suggest that the Global Fund Strategy 212-216 target of distributing 39 million in sub-saharan Africa by 216 will be achieved. Through a partner-based approach to procuring mosquito nets, the Global Fund has achieved substantial cost savings, which are being redirected to the purchase of additional nets. Most affected countries are now able to distribute mosquito nets that cost US$3 per net, a 3 percent reduction from the price of 213, allowing distribution of more than 1 million additional nets for the same overall cost. The number of people who have received ACTs for malaria has surpassed 515 million. The number of homes and other structures that have received indoor residual spraying to prevent the spread of malaria has reached 58 million. Impact and Results 19

Mortality of Children under Five Percentage Decrease in Malaria death rates in Children Under Five (2-213) 8% 6% 4% 2% -2% Nigeria Ethiopia Congo DR Tanzania Uganda Angola Kenya Mozambique Niger Mali Deaths attributed to malaria Deaths from all other causes Source: UNICEF The rate of death for children under the age of five, in 68 malaria-endemic countries supported by Global Fund grants, went down by about one-third between 23 and 213. The decline was faster in countries where the malaria-related share of deaths in children under five was higher. Malaria prevention and treatment contributed to that progress, with particularly big gains in some specific countries. Malnutrition and diarrhea, two of the leading causes of death for children under the age of five, put children at particular risk for malaria; in order to continue to fight malaria in young children, a comprehensive health approach is needed. 1/3 fewer deaths of children under 5 caused by malaria THIS PAGE: A mother and her child wait for consultation at Nimule Hospital. People from all over the country come here because the quality of services is high and treatment is provided for free, including treatments for HIV and TB. South Sudan The Global Fund / John Rae opposite PAGE: Democratic Republic of the Congo The Global Fund / Georges Mérillon The Global Fund 2

Country Example Democratic Republic of Congo Malaria is the leading cause of sickness and death in the Democratic Republic of Congo. Together with Nigeria, DRC accounts for 4 percent of malaria deaths globally. Among children under five, who are most vulnerable to the disease, malaria cases dropped from 158 cases for every 1, people in 27 to 14 cases for every 1, people in 213. The single most important factor in reducing the morbidity and mortality of malaria was the distribution of insecticidetreated nets. Between 24 and 213, approximately 3, lives were saved, but much remains to be done. Work continues, with a primary focus on children under five and pregnant women. In this instance, a health worker at the Mother and Child Hospital in Kinshasa, Democratic Republic of the Congo, provides information on the prevention of malaria and the use of insecticide-treated nets. Lives Saved and Malaria Incidence in Democratic Republic of the Congo (24-212) New Cases ( ) Lives saved, accumulated Disbursements, (US$ Million) Percent of households with at least one mosquito net 27, 3, 45 25, 25, 4 35 27 23, 2, 3 21, 15, 25 2 19, 1, 15 17, 5, 1 5 213 15, 24 26 28 21 212 YEAR Global Fund disbursements to malaria programs New infections, adjusted for popularion growth (left axis) Lives saved (cumulative, left axis) -24 % 25-49 % 5-79 % 8-1 % Source: Malaria Tool (Imperial College) Impact and Results 21

Country Example Viet Nam In Viet Nam, the number of new cases of malaria and of malaria-related deaths have decreased by more than 9 percent since 2. The cumulative number of lives saved by malaria prevention and treatment has risen steadily, with the spread of mosquito nets and artemisininbased treatment. Yet progress has slowed in recent years, as resistance to existing medications has spread. After reducing the number of infections to around 2, in 28, that number rose and declined again slightly in the years that followed. In Vietnam s Tay Ninh province, a mosquito net distribution campaign is giving more children the chance of a malaria-free life. The nearby rubber plantations are a breeding ground for malaria. Making sure there are enough nets and that they are being used properly is an enduring challenge. Viet Nam The Global Fund / Ryan Quinn Mattin Lives Saved and Malaria Incidence in Viet Nam (24-213) New Cases ( ) Lives SAved (cumulative) Disbursements, cumulative (US$ Million) 7 7, 7 6 6, 6 5 5, 5 4 4, 4 3 3, 3 2 2, 2 1 1, 1 24 25 26 27 28 29 21 211 212 213 YEAR Global Fund disbursements to malaria programs New infections, adjusted for population growth (left axis) Lives saved (cumulative, left axis) Source: Malaria Tool (Imperial College) The Global Fund 22

Results Essential Indicators 25 to 214 Number of services supported by the Global Fund (Cumulative) millions, if not specified 25 21 214 HIV Treatment: People currently receiving ARV therapy.4 3.2 8.1 Associated infections: People receiving treatment for sexually transmitted infections.58 11 22 Basic care and support services provided to orphans and other vulnerable children.53 5.6 7.5 Condoms distributed, billions.31 3.1 5.1 Counseling and testing encounters 6.9 173 423 HIV-positive pregnant women receiving ARV prophylaxis for PMTCT.12 1.1 3.1 TB Treatment: people with access to DOTS (smear-positive) 1.5 8.2 13 HIV/TB Associated infections: People receiving treatment for TB/HIV.2 3.4 13 People treated for multidrug-resistant TB, thousands 7.6 52 21 MALARIA Prevention: Insecticide-treated nets distributed 12 194 548 Prevention: Structures covered by indoor residual spraying 4.5 36 58 Treatment: Cases of malaria treated 12 212 515 Cross-Cutting Community outreach prevention services (behavior change communications) 13 211 462 People receiving care and support.8 13 28 Person episodes of training for health or community workers 1.7 14 16 Outreach worker Paula Mengate seeks out long-haul truck drivers like Charles Alwangata at a cross border truckers resting zone near Maputo clearance. Resting zones are hot spots for sex workers to meet up with clients. Paula s job is to provide information about the risk of HIV infection and other sexually transmitted diseases, as well as to give out free condoms. Mozambique The Global Fund / John Rae Impact and Results 23

Progress towards Millennium Development and International Goals in High-impact Countries The Millennium Development Goals have served as a tremendous collective framework that spurred many countries and partners in global health to identify ambitious targets, and then motivated many to achieve those targets. HIV a 47 percent decline in HIV incidence rate and a 28 percent decline in HIV-related death rate between 2 and 214; a 43 percent decline in HIV death rates from their peak in 24. Some targets have been met and surpassed, while others have been more challenging. Millennium Development Goal 6 was set to combat HIV, malaria and other diseases. The target was to halt their growth by 215 and reverse the spread of HIV, and the incidence of malaria and other major diseases. On an aggregate level, Global Fund-supported programs have already met the Millennium Development Goal 6 targets of halting growth and reversing the spread of HIV, TB and malaria. TB a 19 percent decline in TB incidence rate and a 41 percent decline in TB death rate between 2 and 214. Malaria a 34 percent decline in malaria case incidence rate and a 48 percent decline in malaria death rate between 2 and 214. 43% 41% 48% decline in HIV- RELATED death rates from the peak in 24 decline in TB death rates between 2 and 214 decline in malaria death rates between 2 and 214 The Global Fund 24

The following table illustrates a range of remarkable gains towards international targets of reducing incidence and death rates of the three diseases between 2 and 213 (latest published estimates) achieved by 21 high-impact countries where the Global Fund invests. As shown in the table, overall, incidence and deaths rates have declined between 2 and 214 in majority of the Global Fund high-impact countries. In 14 and 9 out of the 21 highimpact countries, HIV incidence and deaths rates declined more than 5 percent, respectively, between 2 and 214. In TB, 17 and 19 out of 21 countries showed a decline in incidence and deaths rate between 2 and 214, respectively. Three and eight of these countries exceeded a 5 percent decline in incidence and death rates, respectively. For malaria, all 21 countries except one showed a decline in incidence and death rates between 2 and 214, with nine countries exceeding a 5 percent decline in incidence and 16 countries exceeding a 5 percent decline in malaria deaths. Percentage Decline in Morbidity and Mortality for AIDS, Tuberculosis and Malaria HIV (2-214) Tuberculosis (2-213) Malaria (2-214) incidence deaths incidence deaths incidence death High Impact Africa - 2 High Impact Africa - 1 Congo (Democratic Republic) 55% 5% -2% 14% 43% 72% Côte d Ivoire 62% 47% 53% 74% 28% 65% Ghana 68% 58% 57% 86% 4% 51% Nigeria 52% 4% -4% 13% 23% 62% South Africa 53% 28% -47% 15% 65% 78% Sudan -1% 4% 36% 6% 62% Ethiopia 83% 78% 47% 69% 74% 74% Kenya 57% 8% 6% -17% 36% 49% Mozambique 57% 9% -5% 25% 37% 74% Tanzania (United Republic) 72% 68% 31% 29% 72% 64% Uganda 11% 77% 6% 78% 56% 85% Zambia 57% 78% 42% 29% 45% 68% Zimbabwe 63% 73% 24% -68% 26% 26% Bangladesh -1% 1% 31% 88% 86% India 62% 11% 24% 5% 46% 46% High Impact Asia Indonesia -1% -1% 11% 64% -3% -38% Myanmar 73% -2% 9% 64% 31% 38% Pakistan -1% -1% 1% 51% 72% 73% Philippines 21% 31% 92% 92% Thailand 73% 67% 32% 5% 5% 96% Viet Nam 49% -99% 28% 44% 88% 89% Source: HIV: UNAIDS 215 report, malaria: WHO Global Malaria Program, TB: WHO 214 Global TB report Increased (capped at 1%) < 25% decline 25-5% decline >5% decline Impact and Results 25

Doctors make rounds in the multidrug-resistant TB ward of Mandalay s Pathein Gyi TB Hospital. Myanmar The Global Fund / John Rae The Global Fund 26

Building Resilient and Sustainable Systems for Health The Ebola crisis in West Africa is a wake-up call a stark reminder that local health threats and weak health systems are global threats that can decimate economies and cause instability. The Ebola crisis also points to unique problems in challenging operating environments and makes poignant the need to understand health as part of a development continuum. This requires differentiated investments that respond to a country s position on the continuum between challenging operating environment and self-sustaining state. The core mission of the Global Fund to end HIV, TB and malaria as epidemics can only be achieved if there are effective systems for health. The Global Fund partnership s investments in HIV, TB and malaria create substantial positive effects on the overall health systems of countries with serious burden of these diseases. This mutually reinforcing relationship between funding for disease-control programs and funding for cross-cutting aspects of health systems is a cornerstone of the Global Fund s approach to investment. Overall, more than onethird of the Global Fund s investments are made in health systems. These investments are delivered in three main ways: (1) support for programs to control HIV, TB and malaria, (2) specific health systems investments, and (3) innovative mechanisms and policies that leverage further support for health systems from both domestic sources and other partners. Freeing Health Systems by Controlling HIV, TB and Malaria Supporting Specific Aspects of Resilient Systems for Health No single international or bilateral organization has the capacity or mandate to support countries to build resilient and sustainable systems for health. Learning from others and from its own investments, the Global Fund is focused on aspects of health systems related to its mission, capacity and ability. Information Systems A thriving health information system is vital for a transformative response to diseases. The Global Fund has invested in building better information systems in low- and middle-income countries. In Ethiopia, for example, the Global Fund is supporting the rollout of an integrated health management information system for all health areas, including maternal and child health, through capacity building of district hospital management teams and health information officers. Ninety-three percent of hospitals and 8 percent of health facilities in the country are implementing the new system. To improve data quality, the Global Fund is providing additional support for health management information system software with the aim of strengthening the use of data for planning and decisionmaking at the district and national levels. Overall, the Global Fund accords special attention to integration of surveillance systems into health management information system for better case reporting and to track notifiable diseases such as Ebola, measles, and cholera. The Global Fund s investments in support of programs to control the diseases have reinvigorated health systems by easing pressure on them as people get healthier. In many countries, investments in ARV therapy have brought benefits to the health system by reducing hospitalizations and decreasing mortality due to HIV. As the number of patients on ARVs increased, hospitalizations decreased dramatically, providing the opportunity to expand hospital admissions for other health needs. Also, fewer people, including health workers, died of AIDS-related complications, allowing domestic resources to be reinvested in other areas of the health system. Increased Allocative Efficiency With needs that are bigger than the resources available, ending epidemics and building health systems requires focused, data-driven approaches that can achieve the greatest impact. Under the Global Fund s funding model, the Technical Review Panel has seen increased prioritization in concept notes. In addition, through a Board-approved special initiative on optimizing value for money, a range of partners have engaged to strategically prioritize interventions to maximize impact a process that is often called allocative efficiency. The Global Fund requires countries to complete an epidemiological analysis to identify disease Building Resilient and Sustainable Systems for Health 27